RTPBC Activities Underway - Point-of-Care Partners...Final Rule Requires at least 50% of all...
Transcript of RTPBC Activities Underway - Point-of-Care Partners...Final Rule Requires at least 50% of all...
Point-of-Care Partners | Proprietary and Confidential
RTPBC Activities Underway
Anthony Schueth, MSCEO & Managing Partner Point-of-Care Partners
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1. The merger of RxHub and Surescripts was a major catalyst in connecting patient identities with a specific formulary 2. NCPDP developed a standard format in which PBMS/payers should send formulary data to EHRs 3. Government regulations helped to push along mandatory use of electronic formulary data by physician practices4. ONC NPRM released in Feb 2014 was the catalyst for NCPDP efforts around RTBI and subsequent demonstration projects.
HIPAA Electronic
Transaction Final Rule
Mandated use of 270/271
eligibility inquiry/response
NCPDP F&B V 3.0
NCPDP Formulary and
Benefit v3.0 adopted
Creation of RxHub and Availability
of Electronic Formulary
RxHub/Surescripts Merger*
Merger of RxHub and Surescripts
Announced
NCPDP F&B V 1.0
NCPDP Formulary and
Benefit v1.0 adopted
CMS MU Stage 2
Final Rule
Requires at least 50% of
all permissible
prescriptions are queried
for drug formulary
MMA Deadline for
eRx Standards
Mandated payers to
support ePrescribing
using standards
July
2008
April
2009
March
2015
August
2012
Jan
2009
Formulary & Benefits/Real-Time Pharmacy Benefit Check (RTPBC)
Timeline
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ONC NPRM
ONC Solicits comments on
NCPDP Telecom and Formulary
and Benefit Standard to support
expanded use cases such as
real-time benefit checks
Feb
2014
April 2015-
March 2018
RTBC Standards
Development & Pilots
Use cases, ONC
demonstration projects, first
RTBC systems and NCPDP
task group efforts
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Addresses Deficiencies in Current Formulary & Benefits
Challenges with accuracy of current Formulary & Benefit data led to a search for a better solution
• Formulary data is based on “Plan-” or “Group”-level; not patient specific
• Prior Authorization flag often missing or inaccurate
• Formulary tier/preferred level often not accurately displayed for HCP
• Issue is payer providing the data, not the standard
Formulary List ID
Coverage List ID
Co-pay List ID
Alternatives List ID
HCPPatient PBM/Processor
Formulary & Benefit
Data Plan MembershipAppointment
IntermediaryEligibility Request
First Name
Last Name
Gender
Birth date
ZIP code
Eligibility Response
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Formulary status
Coverage alerts
Channel options
Member Price
Alternative drugs
Tier or Preferred Level
Age & Quantity Limits, Prior Authorization (PA),
Step Therapy
Retail, Mail Order, Specialty
Member Copay and Cost Sharing Details
Preferred Formulary/ Lower Cost Options
RTPBC Provides Patient Specific Benefit Information
Real-Time Pharmacy Benefit Check (RTPBC) provides patient specific benefit information,
improving transparency and ensuring accurate display of tier/preferred information to health
care professionals (HCPs)
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Real-Time Pharmacy Benefit Check (RTPBC) – Why, How, When
• RTPBC solves data issues surrounding
formulary and benefit information including:
‒ Inaccurate display of preferred status and tier
level
‒ PA indicator missing or incorrect
‒ Benefit information at plan, not patient level
• RTPBC data pulled in real-time and direct from
payer
‒ Provides for more detailed benefit information at
patient level
• Formulary and Benefit files will not
be replaced
‒ Provides “directional” guidance during
the initial prescription decision
• On/Off Formulary -> Formulary Status
• Tier Level -> Copay Tier, Dollar or
Percentage Co-pay
• PA required
• Can help determine if
a RTPBC is even necessary
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Initiate RTPBCRequest
RTPBCResponseIntermediary
Prescription covered by benefit:
• Patient financial responsibility
PBM/Payer
Prescription not covered by benefits:
• Reason for Denial
• Alternatives
• Coverage Limits
RTPBC Response Data Elements
• PA required
• Step therapy
• Drug Utilization Review (DUR) alert
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With a Direct Connection, prescription benefit information comes directly from the
PBM/Payer to the EHR or RTPBC Service Provider. The EHR/RTBC Service Vendor needs
to connect directly to multiple PBMs
EHR/RTPBC
Service Vendor
PBM/Payer
RTPBC Transaction
Assumption: Vendor checks
patient eligibility to confirm where
to send RTPBC transaction
PBM/Payer
PBM/Payer
RTPBC Direct Connection
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Intermediaries already have connections to PBMs/Payers for
formulary information. The existing connections are used to send
and receive an RTPBC transaction
EHR/RTPBC
Service Vendor
PBM/Payer
RTPBC Transaction
PBM/Payer
PBM/Payer
RTPBC Intermediary Solutions
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Intermediary
RTPBC Transaction
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Overall Spend and Volume Trends
Specialty medications continue to be a growing part of overall drug spend, yet Rx volume remains low. Due to the nature
of these medications, the “value” of a single transaction is high
Source: IQIVA Institute Report; Medicines Use and Spending in the U.S. A Review of 2016 and Outlook to 2021 – May 2017
0
50
100
150
200
250
300
350
400
450
2012 2013 2014 2015
0
20
40
60
80
100
120
140
160
180
Total Drug Spend by Category
Market Specialty Traditional
Percent of Total PrescriptionVolume by Category*
Specialty Rx2%
Traditional Rxs98%
*…but there are other transactions that are and could be facilitated to support the process
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2017 Specialty Spend Distribution
35%
21%
37%
6%
MEDICAL BENEFITDistribution by Site of Care
Physician Office Home Outpatient Hospital Other
61%
39%
BENEFIT DISTRIBUTION
Pharmacy Benefit Medical Benefit
Source: 14th Edition, EMD Serono Specialty Digest
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Specialty Medication Stakeholders
Medical Payers
Providers
IDNs
EHRs
Hub & Hub
Services
Pharmacy Benefit
Managers
Manufacturers
Pharmacies
Patient
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The Complexity of Specialty
Drug Dispensing
There is a significant
amount of complexity
involved with
dispensing specialty
medications and a
number of areas to
focus on in regards to
standards and moving
processes electronic
Prescription
Benefit Determination
Enrollment
Copay Assistance
Prior Auth
REMS
Dispense
Deliver
Med Adherence
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The Patient Burden
• Patient out-of-pocket costs vary widely
between medical and pharmacy benefit and
between dispensing sites
• The patient may not be aware of co-pay
assistance programs and may abandon
therapy if co-pay is too high, particularly if
the medication falls under the medical
benefit
• Patients are forced to be their own
advocates
• Employer benefit changes are particularly
challenging for patients and cause therapy
delays that negatively impact outcomes
9%
23%
27%
No
Deductible
Brands with
Deductible
Specialty Brands
with Deductible
Abandonment Rates for Branded Medicines
Almost 1 in 4 Prescriptions Are Abandoned By
Patients During Their Deductible Phase
Source: Amundsen Consulting (a division of QuintilesIMS) analysis for PhRMA; IMS FIA; Rx Benefit Design, 2015
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Addressing Barriers: Da Vinci Project Coverage Requirements
Discovery
• Providers need to easily discover which
payer covered services or devices have
– Specific documentation requirements or
guidance,
– Rules for determining need for specific
treatments/services
– Requirement for Prior Authorization (PA) or
other approvals
• FHIR based API enables providers to
discover payer-specific coverage
requirements in real-time
– Answer to discovery request
– A list of services, templates, documents, rules
– URL to retrieve specific items (e.g. template)
PROVIDER
PAYER
Order Procedure, Lab or Referral
Discover AnyRequirements
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Considerations, Drivers, Future
• Innovators/Early Adopters will help
determine the value and lessons
learned/best practices
• There are costs to both the payers/PBMs
and EHRs
• Formulary and Benefit (F&B) will not go
away with introduction of RTBC;
there’s debate but both are likely needed
• What will drive wide-spread adoption of
RTBC?
• Regulations
• Business model
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Questions?
Thank You!
Tony Schueth, MS CEO & Managing PartnerPoint-of-Care [email protected]